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How do you manage a patient who’s had a stroke?

This Medical Condition is presented by the JCDA Oasis Team and is available on Oasis Help

Definition

  • Stroke (cerebrovascular accident) is a serious and often fatal neurologic event characterized by the rapid appearance (usually over minutes) of a focal deficit of brain function.
  • Pathophysiology: Of patients presenting with a stroke, 85% will have sustained a cerebral infarction due to inadequate blood flow to part of the brain, and the remainder will have had an intracerebral hemorrhage. If a stroke is not fatal, the survivor is often debilitated in motor function and/or speech.
  • Warning signsFour events are associated with a stroke:
    1. The transient ischemic attack (TIA), a “mini” stroke that can last less than 10 minutes;
    2. Reversible ischemic neurological deficit that can last 24 hours before eventual recovery occurs;
    3. Stroke-in-evolution; and
    4. The complete stroke.
  • Strokes happen usually as a complication of another disease (e.g., arrhythmia, carotid artery stenosis/plaque rupture), which should be addressed by the dentist.

Local Anesthetic Precautions

  • Use vasoconstrictors with caution. Increased risk for adverse outcomes.
  • Rare possibility of increased risk of a hypertensive episode followed by bradycardia in patients taking nonselective beta-blockers (e.g., propranolol).
  • Recommendation:
    • Consider limiting epinephrine to 0.04 mg (2 cartridges of 1:100,000 or 4 cartridges of 1:200,000 epinephrine) and levonordefrin to 0.2 mg.
    • Monitor blood pressure and heart rate preoperatively and 5 minutes after injection. Should not treat if systolic BP > 180 mm Hg or if diastolic BP > 110 mm Hg.
    • If multiple quadrants are being treated, the timing of the injections should be spread out (wait 5 minutes before re-administering and monitor patient).
    • Avoid: 1:50,000 concentrations of epinephrine in dental anesthetic and epinephrine-impregnated retraction cord.

Drug Interactions

Prescribe with caution. Adverse interactions likely.

  • NSAIDs and ASA with:
    • Digoxin, captopril, propranolol, diltiazem: Avoid prolonged use of NSAIDs. Limit prescribing to 4 days or less.
  • Antimicrobials (e.g., erythromycin, tetracycline, fluconazole, ketoconazole, miconazole) with:
    • Digoxin: Alters gastrointestinal flora and delays metabolism of digoxin.
    • Phenytoin: Risk of increasing phenytoin blood concentration.
  • Barbiturates, benzodiazepines with:
    • Digoxin: Antagonizes the sedative effects of benzodiazepines.
    • Verapamil: Decreased metabolism of benzodiazepines.

Effects on Bleeding

  • Increased riskMonitor patient: Low-dose ASA (75–325 mg/day), antiplatelet agents (e.g., clopidogrel), and oral anticoagulants (e.g., warfarin, heparin) can increase the risk of surgical and postoperative bleeding.
  • RecommendationManage postoperative pain with acetaminophen-containing products.

Defer Elective Care

  • Avoid elective care for 6 months after a stroke or TIA (“mini” stroke).
  • Provide only urgent dental care during the first 6 months after a stroke or TIA.

Scheduling of Visits

  • Schedule short, stress-free mid-morning appointments.

Orthostatic Hypotension

  • Use supine positioning and discharge patient slowly to avoid orthostatic hypotension.

General Treatment

  • Dental treatment could precipitate or coincide with a stroke. High-risk patients include those who have a history of hypertension, congestive heart failure, diabetes, TIA, and cigarette smoking and those who are > 75 years of age.
  • Use caution, as a fair number of patients may be on coumadin or warfarin.

Oral Manifestations

  • Unilateral atrophy and one-sided neglect
  • Facial palsy
  • Swallowing problems with an increased risk of aspiration

Do you need further information on this topic? Do you have any comments or suggestions? Email us at oasisdiscussions@cda-adc.ca

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5 comments

  1. This is a comprhensive article, thanks. From my experience as a general precaution, vasoconstrictors should not be used with both CVA, or TIA’s, ( and Cardiac patients, especially if there has been an infarction) . The risk is simply too high . Adequate anaesthesia is attainable for most prceedures, with plain anaesthetics for short periods. Appontments should be short duration, perhaps with a mild sedative such as Diazepam. Involved treatment should be postponed .

  2. I would like to disagree with the above comment – The risk of a vaso-constrictor can be eliminated by using an aspirating syringe surely – more important is to keep the anxiety and blood pressure down by good depth of anaesthesia – and effective pain control – and by not giving multiple injections….plus if you want to talk risk – surely potential LA toxicity plays a role here too……especially if patients are older….and you suggest keep topping up with plain solution
    Short appointments are not good for everyone – because people who ened assisstance to attend – or transport – may find multiple visits difficult.
    Finally, I have not read anywhere – the education about oral hygiene products for people with hemi-plegia – crucial to maintain good oral hygiene and independence
    Finally, many patients dependent on others for their attendance at appointments – and post stroke many people cannot drive – cannot drive etc – dont want multiple appointments – because they feel a burden by asking others – so best not to assume or generalise

    • So I have a question, If a patient with history of stroke comes to the clinic in pain and grossly carious 38. What should be the appropriate management protocol?

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